Health Assessment Prep U: Chapter 21= Assessing the Heart and Neck Vessels

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as? Summation gallop Ejection clicks Diastolic clicks Atrial kick

Summation gallop

The nurse is conducting a health history with a female client who reports upper back and jaw pain. In order to assess the client's risk for a cardiac event, which question should the nurse ask first? "Is the pain worse when you are lying down?" "Is the pain worse on exertion?" "Do you have cramping pain?' "Do you have any pain or discomfort in your chest?"

"Do you have any pain or discomfort in your chest?"

The nurse performs an admission assessment on an adult client admitted through the ED with a myocardial infarction. The nurse auscultates a swooshing sound over right carotid artery. What phrase should the nurse use to correctly document this finding? "S2 sound heard over right carotid artery." "Murmur heard over right carotid artery" "Right carotid bruit auscultated" "Split sound auscultated over right carotid artery"

"Right carotid bruit auscultated"

The client is experiencing severe sepsis. What assessment finding would the nurse expect? Respiratory rate 14 1+ pulses Blood pressure 140/80 Heart rate 88

1+ pulses

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? 4th left intercostal space 3rd intercostal space left sternal border 5th left intercostal space midclavicular line 2nd intercostal space left sternal border

2nd intercostal space left sternal border

When auscultating the heart sounds of a client, a nurse notes that the S2 is louder than the S1. How should the nurse describe S2? Diminished Normal split Accentuated Wide split

Accentuated

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what? Gastrointestinal Musculoskeletal Angina Crushing

Angina

When auscultating a client's heart sounds, the nurse hears a louder S2 when listening at the 2nd intercostal space right sternal border. The nurse determines that this finding is consistent with the closure of which heart valves? Pulmonic and tricuspid Mitral and aortic Tricuspid and mitral Aortic and pulmonic

Aortic and pulmonic

When a client is obese or has a thick chest wall, what is difficult to palpate? Apical impulse JVP Sternal angle Grade 4 murmur

Apical impulse

How should a nurse assess a client for pulse rate deficit? Auscultate for split S1 at the base and apex Assess for a difference between the apical and radial pulse Check for pulse inequality between right and left carotid arteries Observe for a decrease in jugular venous pressure

Assess for a difference between the apical and radial pulse

Which statement describes the correct technique by a nurse for use of a stethoscope to auscultate the chest for heart sounds? Auscultate to determine the heart rate and if the rhythm is normal Listen with the bell for the high pitched sounds of normal S1S2 Elevate the head of bed until the examiner can comfortably reach the client Stand at the client's left side and perform the entire assessment from this position

Auscultate to determine the heart rate and if the rhythm is normal

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently? Blood pressure Respiratory rate Heart rate Temperature

Blood pressure

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? Bruits Murmurs Gallops Normal findings

Bruits

A student is asked to define the continuous rhythmic movement of blood during contraction and relaxation of the heart. This best describes which of the following? Cardiac workload Cardiac cycle Cardiac output Cardiac circulation

Cardiac cycle

Which anterior neck structure is found in the depression between the trachea and the sternomastoid muscle? Carotid artery External jugular vein Internal jugular vein Sternomastoid

Carotid artery

A nurse is assessing a client for the presence of stenosis in the carotid arteries. Which of the following should the nurse do? Auscultate for split S1 at the base and apex Check for pulse inequality between right and left carotid arteries Assess for a difference between the apical and radial pulses Observe for a decrease in jugular venous pressure

Check for pulse inequality between right and left carotid arteries

A nurse is unable to palpate the apical impulse on an older client. Which assessment data in the client's history should the nurse recognize as the reason for this finding? Respiratory rate is too fast Heart enlargement is present Heart rate is irregular Client has an increased chest diameter

Client has an increased chest diameter

What is responsible for the inspiratory splitting of S2? Closure of aortic then pulmonic valves Closure of aortic then tricuspid valves Closure of mitral then pulmonic valves Closure of mitral then tricuspid valves

Closure of aortic then pulmonic valves

A nurse understands that the cardiac event that signals the beginning of systole and produces the first heart sound is what? Relaxation of the ventricles Contraction of the ventricles Closure of the aortic and pulmonic valves Closure of the mitral and tricuspid valves

Closure of the mitral and tricuspid valves

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern?

Decreased cardiac output

During an interview with the nurse, a client complains of a fatigue that seems to get worse in the evening. Which of the following causes of fatigue would explain this pattern? Upper respiratory infection Depression Severe muscular exertion Decreased cardiac output

Decreased cardiac output

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds? Aortic Erb point Pulmonic Mitral

Erb point

To function adequately, the nurse knows that the heart valves need to open simultaneously. True False

False

A nurse auscultates a very loud murmur that occurs throughout systole and can be heard with the stethoscope partly off the chest. How should the nurse grade this murmur? Grade 2 Grade 5 Grade 1 Grade 6

Grade 5

How does the nurse differentiate a pleural friction rub from a pericardial friction rub? Auscultate the base of the heart; if a rub is present, it is pericardial Turn the client on the right side; if the rub persists, it is pericardial Auscultate the upper back; if a rub is present, it is pleural Have the client hold his or her breath; if the rub persists, it is pericardial

Have the client hold his or her breath; if the rub persists, it is pericardial

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following? Diabetes mellitus in his extended family Hypertension in his grandparents Heart attacks in his father and siblings Weight patterns within his family

Heart attacks in his father and siblings

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? Hypovolemia Occlusion Constriction Hypervolemia

Hypovolemia

The nurse understands that when the sympathetic nervous system is stimulated what occurs? Select all that apply. Increased cardiac output Decreased cardiac output Increased blood pressure Decreased blood pressure Increased heart rate

Increased cardiac output Increased blood pressure Increased heart rate

The nursing instructor explains to a group of students that what can shorten diastole? Increased heart rate Blood pressure Decreased respirations Filling pressures

Increased heart rate

A client is admitted to the health care facility with reports of chest pain, elevated blood pressure, and shortness of breath with activity. The nurse palpates the carotid arteries as 1+ bilaterally and a weak radial pulse. A Grade 3 systolic murmur is auscultated. Which nursing diagnosis can the nurse confirm based on this data? Ineffective Health Maintenance Activity Intolerance Impaired Breathing Pattern Ineffective Tissue Perfusion

Ineffective Tissue Perfusion

What nursing diagnosis would be most appropriate for a client admitted with heart failure? Ineffective tissue perfusion Risk for denial Impaired gas exchange Acute pain

Ineffective tissue perfusion

A nurse cares for a client who suffered a myocardial infarction 2 days ago. A high-pitched, scratchy, scraping sound is heard that increases with exhalation and when the client leans forward. The nurse recognizes this sound as a result of what process occurring within the pericardium? Inflammation of the pericardial sac Increased pressure within the ventricles Incompetent mitral valve Inability of the atria to contract

Inflammation of the pericardial sac

Before the nurse begins the physical examination of a client with congestive heart failure, the client reports having to get up at night to void frequently. Which action should the nurse take in response to the client's report? Ensure that the client lies flat for the examination. Palpate the carotid pulse. Inspect for dependent edema. Assess for thrills.

Inspect for dependent edema.

Across the lifespan, a nurse knows what characteristic of the female heart is consistently true? Is normally smaller than the male heart Is normally larger than a male heart Weighs more than a male heart Normally beats more slowly than a male heart

Is normally smaller than the male heart

To assess the function of the right side of the heart, a nurse should perform which part of the heart and neck vessel assessment? Carotid artery pulse Apical impulse Heart sounds Jugular venous pulse

Jugular venous pulse

A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur? Mitral Aortic Tricuspid Pulmonic

Mitral

A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur? Mitral Pulmonic Aortic Tricuspid

Mitral

The event producing the first heart sound (S1) is closure of which of the following valves? Tricuspid Pulmonic Aortic Mitral

Mitral

During auscultation of the heart, the nurse notes a swooshing sound. The nurse would document this as what? Murmur Extra sound Vibration Flutter

Murmur

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following? S1 Murmur S2 Ventricular gallop

Murmur

A 58-year-old teacher presents with breathlessness with activity. The client has no chronic conditions and does not take any medications, herbs, or supplements. Which of the following symptoms is appropriate to ask about in the cardiovascular review of systems? Hematochezia Abdominal pain Orthopnea Tenesmus

Orthopnea

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what? Orthopnea Pneumonia Sleep apnea Tachypnea

Orthopnea

What is the most important physical sign of acute pericarditis? Murmur heard over the left sternal border Pericardial friction rub Intense pain Elevated white cell count

Pericardial friction rub

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound? Aortic ejection click Pericardial friction rub Split sound Pericardial murmur

Pericardial friction rub

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse use to listen to this condition? With the client supine, place the bell of the stethoscope on the 2nd left intercostal space. With the client leaning forward, listen over the left carotid artery. Use the diaphragm of the stethoscope to listen over the right sternal border. Place the bell of the stethoscope over the apex with client on left side.

Place the bell of the stethoscope over the apex with client on left side.

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest? Left sternal border , 3rd ICS Left mid-clavicular line, 5th ICS Right sternal border 4th ICS Right sternal border, 2nd ICS

Right sternal border, 2nd ICS

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? Afterload Preload S1 S2

S2

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what? Surgical site infection Increased intracranial pressure Cardiac dysrhythmias Severe sepsis

Severe sepsis

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? Painful breathing Shortness of breath Rapid breathing Inability to breathe

Shortness of breath

A client comes to the emergency department reporting a sudden onset of dyspnea. What finding is a manifestation of dyspnea? Rapid breathing Painful breathing Shortness of breath Inability to breathe

Shortness of breath

While completing the cardiovascular system health history, a client reports difficulty falling asleep unless she is in an upright position. Which of the following potential problems should the nurse further investigate? Chest pain Palpitations Shortness of breath Edema

Shortness of breath

The nurse notes that a client's heart rate increases with inspiration and slows down with expiration. How should the nurse document this finding? Sinus bradycardia Premature atrial contractions Premature ventricular contractions Sinus arrhythmia

Sinus arrhythmia

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply. Family history Cholesterol Age Blood pressure Smoking

Smoking Blood pressure Cholesterol

A 52-year-old man is skeptical about the potentially harmful effect of his smoking on his heart, citing the fact that both his father and grandfather lived long lives despite being lifelong smokers. Which of the following facts would underlie the explanation that the nurse provides the client? Smoking increases the heart's workload and contributes to atherosclerosis. Smoking decreases the contractility of the myocardium and contributes to valvular disorders. Smoking is a central component of metabolic syndrome. Smoking damages the cardiac conduction system, resulting in dysrhythmias that are entirely preventable.

Smoking increases the heart's workload and contributes to atherosclerosis.

The sternal angle at the right 2nd rib space is also known as what? The tricuspid area Erb's point The aortic area The mitral area

The aortic area

Which of the following assessment findings would signal a pathophysiological finding to the nurse? S2 is split when the nurse asks the client to inhale deeply but is not split on exhalation. The intensity of the client's S1 varies between beats. S1 is softer than S2 when the nurse listens at the base of the client's heart. Auscultation at the client's apex reveals that S1 is louder than S2.

The intensity of the client's S1 varies between beats.

A new nurse on the telemetry unit is reviewing information about how to correctly read electrocardiograms. The nurse is expected to know that the PR interval represents what event? The spread of depolarization in the atria The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle The spread of depolarization and sodium release in the ventricles to cause ventricular contraction Relaxation of the ventricles and repolarization of the cells

The time from firing of the sinoatrial (SA) node to the beginning of depolarization in the ventricle

The nurse on the cardiac unit is caring for a client who thinks he was having a myocardial infarction when he came to the emergency department. When reviewing laboratory data on this client, the nurse notes that all tests are within normal limits except for the cholesterol and C-reactive protein, both of which are elevated outside the normal range. The nurse should be aware of what fact relating to elevated cholesterol and C-reactive protein? They have no direct correlation with increased risk of cardiac disease. They are both sensitive and specific to heart failure. They more than double the risk of cardiac disease. They are clinical proof that the client had a coronary event.

They more than double the risk of cardiac disease.

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply. Choose foods like bananas and sweet potatoes. Increase consumption of dairy products. Use a low sodium seasoning to flavor food. Consume two to three glasses of red wine daily. Walk briskly 30 minutes per day.

Walk briskly 30 minutes per day. Use a low sodium seasoning to flavor food. Choose foods like bananas and sweet potatoes.

The client is known to have a bundle branch block that delays activation of the right ventricle as a result of a recent myocardial infarction (MI). What would the nurse expect to hear when auscultating the client's heart sounds? An opening snap Wide splitting Arrhythmia S3 sound

Wide splitting

A client complains of chest pain. The nurse understands that chest pain can have causes other than cardiac pain, thus follows up with the client regarding the timing and quality of this pain. Which of the following would indicate cardiac pain as opposed to other types? Select all that apply. Has a squeezing sensation around the heart Worsens with activity Is relieved with antacids Radiates to left shoulder and down the left arm May occur at any time Tends to occur after meals

Worsens with activity May occur at any time Radiates to left shoulder and down the left arm Has a squeezing sensation around the heart

During a cardiac examination, the nurse can best hear the S1 heart sound by placing the stethoscope at the client's second left interspace. base of the heart. apex of the heart. pulmonic valve area.

apex of the heart.

The nurse is preparing to assess the cardiovascular system of an adult client with emphysema. The nurse anticipates that there may be some difficulty palpating the client's jugular veins. apical pulse. carotid arteries. breath sounds.

apical pulse.

The nurse hears a quiet murmur immediately after placing the stethoscope on the chest. Documentation of grading for this murmur would include grade 3 grade 4 grade 1 grade 2

grade 2

The nurse assesses a hospitalized adult client and observes that the client's jugular veins are fully extended. The nurse contacts the client's physician because the client's signs are indicative of increased central venous pressure. diastolic murmurs. patent ductus arteriosus. pulmonary emphysema.

increased central venous pressure.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? left midclavicular line at the fifth intercostal space right of the midclavicular line at the third intercostal space right of midclavicular line at the fifth intercostal space left midclavicular line at the third intercostal space

left midclavicular line at the fifth intercostal space

The nurse hears a murmur in a client with a known mitral valve prolapse. The murmur most likely occurs in mid-diastole early diastole late systole mid-systole

late systole

While conducting a physical examination of the cardiovascular system, the nurse hears fine crackles on auscultation of the lungs. This finding is most likely a manifestation of which problem? hypertension left-sided heart failure palpitations dextrocardia

left-sided heart failure

The nurse detects paradoxical pulses in an adult client during an examination. The nurse should explain to the client that paradoxical pulses are usually indicative of left-sided heart failure. premature ventricular contractions. aortic stenosis. obstructive lung disease.

obstructive lung disease.

The anterior chest area that overlies the heart and great vessels is called the precordium. endocardium. epicardium. myocardium.

precordium.

The nurse notes that a client's heart rate speeds up with inspiration and slows down with expiration. What should the nurse suspect this client is demonstrating? premature ventricular contractions sinus arrhythmia premature atrial contractions atrial fibrillation

sinus arrhythmia